Disparities in Breast Cancer Characteristics Among Syrian Migrants and Jordanian Women in the Jordan Cancer Registry from 2010 to 2016.

This case series analyzes breast cancer characteristics of women diagnosed with breast ancer in the Jordan Cancer Registry by Syrian migrant status to determine inequities.

Incidence of Cancer in Adolescents and Young Adults in Jordan, 2000-2017.

PURPOSE: The epidemiology of cancer in adolescents and young adults (AYAs) is distinct and underinvestigated. Therefore, we investigated the incidence of cancer in AYAs in Jordan. PATIENTS AND METHODS: We accessed all records submitted to the Jordan Cancer Registry between 2000 and 2017. We included all patients, age 15-39 years, who were ordinarily resident in Jordan. We then calculated frequencies, age-adjusted incidence rates (AAIRs), and annual percentage changes (APCs) and performed subgroup analyses by biologic sex, age subgroups, and site (SEER AYA site recode/WHO 2008). We also performed site-specific trend analyses using joinpoint models. RESULTS: We identified 14,115 eligible patients, of whom 1,531 (10.8%), 4,278 (30.3%), and 8,306 (58.8%) were 15-19, 20-29, and 30-39 years old at diagnosis, respectively. The numbers of male and female AYAs were 5,792 (41.0%) and 8,323 (59.0%), respectively. The crude number of cases increased from 654 in 2000 to 954 in 2017 (APC, 2.6%). The overall AAIR ranged from 32.3 in 2000 to 24.3 in 2017 (APC, -1.7%). The AAIR was 27.6 over the full study period and was higher in females (34.1) than in males (21.6). Carcinomas, lymphomas, and leukemias were the most common cancers. The incidence rates of the majority of cancers trended downward over the study period. CONCLUSION: The incidence of cancer in AYAs in Jordan is relatively low and declining. However, the absolute number of cases is increasing because this downtrend does not offset the effect of a high population growth rate; almost a 1,000 cases of cancer are now diagnosed every year, which represents a significant increase in the burden of cancer in a developing country with limited healthcare resources.

Changing Mortality and Place of Death in Response to Refugee Influx: A Population-Based Cross-Sectional Study in Jordan, 2005-2016.

Background: Jordan faces complex health care challenges due to refugee influx and an aging population. Palliative care planning and delivery require data to ensure services respond to changing population needs. Objectives: To determine the trend in mortality and place of death in Jordan. Design: Population-based study. Setting/Subjects: Death registry data of adult decedents (n = 143,215), 2005-2016. Measurements: Descriptive statistics examined change in demographic and place of death (categorized as hospital and nonhospital). Binomial logistic regression compared the association between hospital deaths and demographic characteristics in 2008-2010, 2011-2013, and 2014-2016, with 2005-2007. Results: The annual number of deaths increased from 6792 in 2005 to 17,018 in 2016 (151% increase). Hospital was the most common place of death (93.7% of all deaths) in Jordan, and percentage of hospital deaths increased for Jordanian (82.6%-98.8%) and non-Jordanian decedents (88.1%-98.7%). There was an increased likelihood of hospital death among Jordanian decedents who died from nonischemic heart disease (odd ratio [OR]: 1.11, 95% confidence interval [CI]: 1.09-1.13, p < 0.001), atherosclerosis (OR: 1.10, 95% CI: 1.08-1.13, p < 0.001), renal failure (OR: 1.05, 95% CI: 1.02-1.08, p < 0.001), hemorrhagic fevers (OR: 1.09, 95% CI: 1.06-1.13, p < 0.001), and injury (OR: 1.18, 95% CI: 1.06-1.33, p < 0.001) in the period 2014-2016, compared with 2005-2007. There were similar increases in the likelihood of hospital death among non-Jordanians in 2014-2016 for the following conditions: malignant neoplasms (except leukemia), nonischemic heart disease, atherosclerosis, injury, and HIV, compared with 2005-2007. Conclusions: Country-level palliative care development must respond to both internal (aging) and external (refugee influx) population trends. Universal Health Coverage requires palliative care to move beyond cancer and meet population-specific needs. Community-based services should be prioritized and expanded to care for the patients with nonischemic heart disease, atherosclerosis, renal failure, hemorrhagic fevers, and injury.

Survival Rate of Gastric Cancer Patients in Jordan: Secondary Data Analysis.

BACKGROUND: Gastric cancer accounts for 2.7% of all newly diagnosed cancer cases in Jordan. OBJECTIVE: The aim of this study was to calculate the survival rate and its determinants among Jordanian patients who were diagnosed with gastric cancer between 2010 and 2014. METHODS: A descriptive study was conducted based on secondary analysis of data from the Jordan Cancer Registry during the period of 2010-2014. Only cancer-related deaths were recorded as "death" in the survival analysis. RESULTS: A total of 1388 new cases of gastric cancer were recorded between 2010 and 2014. Of these, 872 (62.8%) were Jordanians and 60.5% were males. The mean age at diagnosis was 58.9 years and the median follow-up time was 1.6 years. The 5-year survival rate decreased significantly from 89% in patients with well-differentiated cancer to 32% in patients with poorly differentiated cancer (P=.005). The overall 5-year survival rate was 37.7% and the median survival was 1.48 years (95% CI 1.179-1.783). The 5-year survival rate decreased significantly with increasing age and with advanced stage of the disease: the 5-year survival rate was 75% for localized-stage, 48% for regional-stage, and 22.7% for distant-metastasis disease (P=.005). CONCLUSIONS: This study showed that the overall 5-year survival rate among patients with gastric cancer in Jordan between 2010 and 2014 was 37.7%, which is higher than the reported rates from different countries in the Eastern Mediterranean region such as Egypt.

Spatial and temporal characteristics of cancer in the period from 2004 to 2013 in the Hashemite Kingdom of Jordan.

Cancer in Jordan is a major public health problem and the second leading cause of death after heart disease. This study aimed at studying the spatial and temporal characteristics of cancer in Jordan and its 12 governorates for the period 2004-2013 to establish a baseline for future research and identification of cancer risk factors paving the way for developing a cancer control plan in the country. Numerical and graphical summaries, time-series additive seasonal decomposition, the method of least squares, and spacetime scan statistics were applied in a geographic information systems environment. Although the results indicate that the cancer incidence in Jordan is comparatively low, it is increasing over time. In the 10-year study period, a total of 44,741 cases was reported with a mean annual crude incidence rate of 68.4 cases/100,000, mean annual age-adjusted incidence rate of 111.9 cases/100,000, and a monthly rate increase of 1.2 (cases/100,000)/month. This study also revealed that the spatial and temporal characteristics of cancer vary among the governorates. Amman, which includes the capital city and hosts more than one-third of the population of the country, reported 61.0% of the total number of cases. Amman also reported the highest annual crude incidence rate (105.3 cases/100,000), the highest annual age-adjusted incidence rate (160.6 cases/100,000), and the highest rate of increase (0.7 (cases/100,000)/month) forming a high-rate cluster. Excluding the three governorates Amman, Balqa, and Ma'daba, low-rate clusters were found with regard to the remaining governorates. All governorates, except Irbid and Mafraq, showed significant rates of increase of cancer incidence. However, no clear seasonality pattern with respect to cancer incidence was discerned.

The Epidemiology and Trend of Cancer in Jordan, 2000-2013.

OBJECTIVES: This study aimed to determine the overall incidence, trend, and epidemiology of cancer among Jordanians from 2000 to 2013 using data extracted from Jordan's Cancer Registry (JCR). METHODS: All cancer cases among Jordanians registered between 2000 and 2013 were analyzed using CanReg software and SPSS. The overall crude incidence rates (CIRs) and the age standardized rates (ASRs) of cancer per 100,000 were calculated. RESULTS: A total of 58788 cancer cases were registered during the period 2000-2013. Of those, 28545 (48.6%) were males and 30243 (51.4%) were females. About three-quarters (77.3%) of the registered patients were ≥ 40 years in age. Overall, the average crude cancer incidence rate was 82.8/100,000 population during the 14-year study period. On the other hand, the ASR was 126/100,000 during the same period (124.2 /100,000 for males and 128.4 /100,000 for females). The cumulative top cancers among males were colorectal, lung, lymphoma, urinary bladder, and prostate, respectively, while those among females were breast, colorectal, lymphoma, thyroid, and uterine. The number of cancer cases has increased from 3370 in 2000 to 5409 in 2013 (60.5% increase over the 14 years). The percentage of increase was 68.4% in females and 52.5% in males. The ASR has also increased from 113.6 per 100,000 in 2000 to 142.1 per 100.000 in 2013 with a 25.1% of increase during the 14 years. CONCLUSION: Over the 14-year study period, incidence of cancer in Jordan has increased. However, it remains lower than that in other Eastern Mediterranean and Western countries. We recommend initiating screening programs for the most common types of cancer in Jordan that have valid screening tests to detect cancer during its early stages and reduce overall morbidity and mortality.

Development of an automated phenotyping algorithm for hepatorenal syndrome.

OBJECTIVE: Hepatorenal Syndrome (HRS) is a devastating form of acute kidney injury (AKI) in advanced liver disease patients with high morbidity and mortality, but phenotyping algorithms have not yet been developed using large electronic health record (EHR) databases. We evaluated and compared multiple phenotyping methods to achieve an accurate algorithm for HRS identification. MATERIALS AND METHODS: A national retrospective cohort of patients with cirrhosis and AKI admitted to 124 Veterans Affairs hospitals was assembled from electronic health record data collected from 2005 to 2013. AKI was defined by the Kidney Disease: Improving Global Outcomes criteria. Five hundred and four hospitalizations were selected for manual chart review and served as the gold standard. Electronic Health Record based predictors were identified using structured and free text clinical data, subjected through NLP from the clinical Text Analysis Knowledge Extraction System. We explored several dimension reduction techniques for the NLP data, including newer high-throughput phenotyping and word embedding methods, and ascertained their effectiveness in identifying the phenotype without structured predictor variables. With the combined structured and NLP variables, we analyzed five phenotyping algorithms: penalized logistic regression, naïve Bayes, support vector machines, random forest, and gradient boosting. Calibration and discrimination metrics were calculated using 100 bootstrap iterations. In the final model, we report odds ratios and 95% confidence intervals. RESULTS: The area under the receiver operating characteristic curve (AUC) for the different models ranged from 0.73 to 0.93; with penalized logistic regression having the best discriminatory performance. Calibration for logistic regression was modest, but gradient boosting and support vector machines were superior. NLP identified 6985 variables; a priori variable selection performed similarly to dimensionality reduction using high-throughput phenotyping and semantic similarity informed clustering (AUC of 0.81 - 0.82). CONCLUSION: This study demonstrated improved phenotyping of a challenging AKI etiology, HRS, over ICD-9 coding. We also compared performance among multiple approaches to EHR-derived phenotyping, and found similar results between methods. Lastly, we showed that automated NLP dimension reduction is viable for acute illness.

Incidence patterns of colorectal cancers in four countries of the Middle East Cancer Consortium (Cyprus, Jordan, Israel, and Izmir, Turkey) compared with those in the United States Surveillance, Epidemiology, and End Results Program.

BACKGROUND/AIMS: There are wide variations in colorectal cancer (CRC) incidence across the world. Historically, the highest incidence rates have been reported historically in more developed countries; however, increasing trends have been seen in developing countries. Here, we present the CRC incidence pattern in Cyprus, Israel, Jordan, and Izmir, Turkey, which are countries of the Middle East Cancer Consortium (MECC). MATERIALS AND METHODS: We analyzed 2005-2010 CRC data from population-based registries and calculated crude and age standardized rates for CRC, colon and rectum subsites, and annual percent changes (APCs) for trends. RESULTS: The age-adjusted incidence rates (AAIRs) for CRC were the highest in Israeli Jews (IJ) (46.7 for males and 35.5 for females), which exceeded those of the USA Surveillance, Epidemiology, and End Result (SEER) program registries. In both sexes, AAIRs in Cyprus and Israeli Arabs (IA) were close to those in SEER registries. For both sexes, AAIRs in Izmir and Jordan were substantially lower than those in other registries. Statistically significant decreasing trends over time were observed in AAIRs for both sexes in the SEER program (APCs: males, -3.24% and females, -2.54%), whereas the trends varied within the MECC registries. There were decreasing AAIR trends for males in IJ and IA and for females in Cyprus and IJ; APC for females in IJ (-4.29%) was significant. Conversely, increasing trends with the significant APCs were observed in males in Izmir (2.43%) and Jordan (7.57%). CONCLUSION: MECC countries comprise both high- and low-risk populations for CRCs. However, increasing trends in low-risk populations have been alarming. Thus, the need for implementing tailored primary and secondary prevention programs in the region is essential.

Cancer surveillance in northern Africa, and central and western Asia: challenges and strategies in support of developing cancer registries.

The Global Initiative for Cancer Registry Development partnership, led by the International Agency for Research on Cancer (IARC), was established in response to an overwhelming need for high-quality cancer incidence data from low-income and middle-income countries. The IARC Regional Hub for cancer registration in North Africa, Central and West Asia was founded in 2013 to support capacity building for cancer registration in each of the countries in this region. In this Series paper, we advocate the necessity for tailored approaches to cancer registration given the rapidly changing cancer landscape for this region, and the challenges faced at a national level in developing data systems to help support this process given present disparities in resources and health infrastructure. In addition, we provide an overview of the status of cancer surveillance and activities country-by-country, documenting tailored approaches that are informing local cancer-control policy, and potentially curbing the growing cancer burden across the region.

Refugees in Conflict: Creating a Bridge Between Traditional and Conventional Health Belief Models.

The recent wave of migration from Middle Eastern countries to Europe presents significant challenges to the European health profession. These include the inevitable communication gap created by differences in health care beliefs between European oncologists, health care practitioners, and refugee patients. This article presents the conclusions of a workshop attended by a group of clinicians and researchers affiliated with the Middle East Cancer Consortium, as well as four European-based health-related organizations. Workshop participants included leading clinicians and medical educators from the field of integrative medicine and supportive cancer care from Italy, Germany, Turkey, Israel, Palestine, Iran, Lebanon, Jordan, Egypt, and Sudan. The workshop illustrated the need for creating a dialogue between European health care professionals and the refugee population in order to overcome the communication barriers to create healing process. The affinity for complementary and traditional medicine (CTM) among many refugee populations was also addressed, directing participants to the mediating role that integrative medicine serves between CTM and conventional medicine health belief models. This is especially relevant to the use of herbal medicine among oncology patients, for whom an open and nonjudgmental (yet evidence-based) dialogue is of utmost importance. The workshop concluded with a recommendation for the creation of a comprehensive health care model, to include bio-psycho-social and cultural-spiritual elements, addressing both acute and chronic medical conditions. These models need to be codesigned by European and Middle Eastern clinicians and researchers, internalizing a culturally sensitive approach and ethical commitment to the refugee population, as well as indigenous groups originating from Middle Eastern and north African countries. IMPLICATIONS FOR PRACTICE: European oncologists face a communication gap with refugee patients who have recently immigrated from Middle Eastern and northern African countries, with their different health belief models and affinity for traditional and herbal medicine. A culturally sensitive approach to care will foster doctor-refugee communication, through the integration of evidence-based medicine within a nonjudgmental, bio-psycho-social-cultural-spiritual agenda, addressing patients' expectation within a supportive and palliative care context. Integrative physicians, who are conventional doctors trained in traditional/complementary medicine, can mediate between conventional and traditional/herbal paradigms of care, facilitating doctor-patient communication through education and by providing clinical consultations within conventional oncology centers.

Higher defibrillation threshold in methamphetamine cardiomyopathy patients with implantable cardioverter-defibrillator.

INTRODUCTION: Identification of patients with an increased risk of high defibrillation thresholds (DFTs) is important in planning implantable cardioverter-defibrillator (ICD) procedures. Clinical observations have suggested that patients with methamphetamine cardiomyopathy (MACMP) have significantly elevated defibrillation thresholds. We hypothesized that MACMP patients would have higher DFT thresholds than controls and would require procedural changes during ICD implantation to accommodate higher thresholds. METHODS: We identified consecutive patients with MACMP undergoing ICD implantation at the academic center from 2003 to 2007. We then compared DFTs against age-and sex-matched controls. RESULTS: The MACMP (n = 10) group showed significantly increased DFT thresholds (23.7 ± 6.7 J) compared with age and sex-matched controls (14.5 ± 4.6 J, p < 0.005). Additionally, patients with MACMP had evidence of more severe congestive heart failure, with increased B-type natrieutic protein (BNP) levels (1173 ± 784 vs 260 ± 349, p = 0.02) and decreased left ventricular ejection fraction (LVEF) (17.8 ± 9.4 vs 35.9 ± 15.2, p = 0.02). MACMP patients required high output devices than controls (50% versus 0%, p = 0.03). Differences between groups remained significant despite adjusting for LVEF. CONCLUSIONS: Planning for ICD implantation should take into consideration a history of methamphetamine abuse, mandating DFT testing and empiric consideration of high output devices for such patients.

Integrating Complementary and Traditional Practices in Middle-Eastern Supportive Cancer Care.

The Middle East is a promising arena in which researchers can explore the interchange between cross-cultural traditional medicine and supportive cancer care, as provided within an integrative oncology setting. Integrative oncology research and clinical practice in this part of the world have been focusing, for the most part, on the use of herbal medicine and mind-body-spiritual modalities, both of which are deeply rooted in traditional medical care. A regional, multinational, and interdisciplinary collaboration is currently being undertaken as part of the academic activities of the Middle-East Research Group in Integrative Oncology (MERGIO). This group is part of the Middle-East Cancer Consortium, a body supported by the National Cancer Institute. MERGIO currently facilitates a number of innovative educational, basic science, and clinical research projects that are investigating the effectiveness and safety of traditional herbal remedies. In order to create a structured, pragmatic "bedside-to-bench" and subsequent "back-to-bedside" approach, MERGIO has designed a patient-tailored integrative oncology model of supportive-palliative care. This approach addresses both patients' individual health belief models and the larger social-cultural-religious context, as defined by the health-related values of the patient's community.

Trends in the Incidence of Cervical Cancer in Jordan, 2000-2013.

OBJECTIVES: To determine the incidence of cervical cancer in Jordan and assess its trend in over a 14-year period (2000-2013). METHODS: This descriptive study was based on secondary analysis of cervical cancer data that are registered in the Jordan Cancer Registry (JCR). RESULTS: A total of 591 women were diagnosed with cervical cancer in Jordan during the period 2000-2013. The age at diagnosis ranged between 15 and 97 years, with a median of 50 years. The average age standardized rate (ASR) was 2.0/100,000 women. The incidence of cervical cancer started to decrease after 2006 but it remained relatively constant between 2008 and 2013. Over the 14-year period, ASR for cervical cancer decreased by 28.6% from 2.1 per 100,000 women in 2000 to 1.5 per 100,000 women in 2013. About 46.5% of the cases were of squamous cell carcinoma morphology. Early cancer constituted about 60% of the cases, regional cases constituted 9.6%, and distant metastatic cases constituted 10.7%. CONCLUSIONS: The incidence of cervical cancer in Jordan is low compared to regional estimates and remained relatively constant between 2008 and 2013. Implementation of screening measures could lead to better case finding, early diagnosis, and prevention of cervical cancer.

Colorectal Cancer in Jordan: Survival Rate and Its Related Factors.

Objectives. To estimate the survival rate of colorectal cancer (CRC) and determine its predictors among Jordanian patients who were diagnosed in the period of 2005-2010. Methods. This study was based on Jordan cancer registry. All CRC cases that were registered in cancer registry during 2005-2010 were analyzed using the survival analysis. The last date for follow-up was 1st Oct 2016. Results. A total of 3005 patients with CRC were registered during 2005-2010. The overall 5-year and 10-year survival rates for patients with CRC were 58.2% and 51.8%, respectively. The 5-year survival rate decreased significantly from 60.4% for the age <50 years to 49.3% for the age ≥70 years (p < 0.005). The 5-year survival rate was 72.1% for the localized stage, 53.8% for the regional stage, and 22.6% for the distant metastasis. In the multivariate analysis, the only factors that were significantly associated with survival were age, grade, stage, and location of tumor. Conclusions. The overall 5-year and ten-year survival rates for CRC were 58.2% and 51.8%, respectively. Increased age, poor differentiation, advanced cancer stage, and right-sided cancers were associated with lower survival rates. Screening strategies are needed for early detection of colon adenomas and colorectal cancer in Jordan.

Cancer burden in four countries of the Middle East Cancer Consortium (Cyprus; Jordan; Israel; Izmir (Turkey)) with comparison to the United States surveillance; epidemiology and end results program.

It is important that population-based cancer registries provide accurate and reliable data for public health purposes. These data are essential data for planning of cancer control and prevention. In this study, we examined cancer incidence rates (year 2005-2010) in four MECC registries (Cyprus, Jordan, Israel, Izmir (Turkey)) and compared with the rates in the US. The overall age-standardized incidence rates for males were highest in the US followed by Israeli Jews, Izmir (Turkey), Cyprus, Israeli Arabs, and lowest in Jordan. In women the rates of cancer of all sites were also highest in US women followed by Israeli Jews, Cyprus, Israeli Arabs, Izmir (Turkey), and lowest in Jordan. It is of interest that although site-specific cancer rates differ between the countries studied, prostate, lung and colorectal cancers are within the five most common cancers males in all countries studied. In females, breast colorectal and endometrium cancers are three of the five most common cancers in females in all countries studied. The results presented in this paper can have implications for opportunities in cancer control and prevention in these countries. Future studies on individual cancer sites with highest rates in these Countries are currently underway.

Communication and integration: a qualitative analysis of perspectives among Middle Eastern oncology healthcare professionals on the integration of complementary medicine in supportive cancer care.

CONTEXT AND OBJECTIVES: The use of complementary and traditional medicine (CTM ) in Middle Eastern countries is widespread, including among patients with cancer. Perspectives of oncology healthcare professionals (HCPs) in this region regarding the integration of CTM within conventional supportive cancer care were explored. METHODS: An 11-item questionnaire with an open-ended question asking respondents to comment about the integration of CTM within supportive cancer care was sent to Middle Eastern oncology HCPs, using snowball sampling methodology. The narratives provided were examined using thematic analysis. RESULTS: A total of 339 oncology HCPs completed and returned the study tool (80.3 % response rate ), of which 178 from 15 Middle Eastern countries responded to the open-ended question. The majority of respondents are in favor of the integration of CTM within supportive cancer care, though ideas on how this should be implemented varied. Thematic analysis identified multifactorial barriers to integration, which focused on HCPs' perspectives (e.g., a lack of knowledge and training; a skeptical approach to CTM), attitudes of patients and caregivers (e.g., unrealistic expectations regarding the outcomes of CTM treatments) and HCP-patient communication. In order to overcome these barriers, respondents suggested education and training programs for oncology HCPs which would focus on improving patients' quality-of-life-related outcomes. CONCLUSIONS: Middle Eastern oncology HCPs support the integration of CTM within supportive cancer care, while recognizing the need for education and training in this field. A better understanding of CTM would provide the knowledge and skills which would promote a non-judgmental, evidence-based approach, fostering better communication with patients.

Middle Eastern Conflicts: Implications for Refugee Health in the European Union and Middle Eastern Host Countries.

Until very recently, health care in conflict settings was based on a model developed in the second half of the twentieth century. Things have changed, and present civil wars, such as those that are currently taking place in the Middle East, do not address the complexity of the ongoing armed conflicts in countries such as Syria, Iraq, and Afghanistan. These conflicts have caused a significant increase in the number of refugees in the region, as well as in Europe. Hundreds of thousands of refugees succeed in settling in mid- and north-European countries, and their health issues are becoming of great importance. Refugees in Europe in the twenty-first century do not suffer so much from infectious diseases but more from noninfectious chronic diseases such as diabetes, cardiac disease, and cancer. These facts profoundly alter the demographics and disease burden of hostility-derived migrants. Thus, host European countries face situations they have never faced before. Hence, new approaches and strategies are urgently needed to cope with this new situation. The efforts to absorb refugees of different traditions and cultural backgrounds often cause increasing ethnic and religious tensions, which frequently escort the emergence of social violence. To date, little attention has been paid to the overall load of distress being experienced, especially among the first-generation refugees. The current ongoing hostilities in the Middle East induce a long-term health impact on people expelled from their homes, communities, traditions, and cultural environment. The realization of collective suffering forces communities and governmental health agencies to develop new programs that include social determinants to overcome the severe cultural gaps of the newcomers in their new European host countries.

Potential risks associated with traditional herbal medicine use in cancer care: A study of Middle Eastern oncology health care professionals.

BACKGROUND: The authors assessed the use of herbal medicine by Middle Eastern patients with cancer, as reported by their oncology health care professionals (HCPs). Herbal products identified by the study HCPs were evaluated for potential negative effects. METHODS: Oncology HCPs from 16 Middle Eastern countries received a 17-item questionnaire asking them to list 5 herbal products in use by their patients with cancer. A literature search (PubMed, Micromedex, AltMedDex, and the Natural Medicine Comprehensive Database) was conducted to identify safety-related concerns associated with the products listed. RESULTS: A total of 339 HCPs completed the study questionnaire (response rate of 80.3%), identifying 44 herbal and 3 nonherbal nutritional supplements. Safety-related concerns were associated with 29 products, including herb-drug interactions with altered pharmacodynamics (15 herbs), direct toxic effects (18 herbs), and increased in vitro response of cancer cells to chemotherapy (7 herbs). CONCLUSIONS: Herbal medicine use, which is prevalent in Middle Eastern countries, has several potentially negative effects that include direct toxic effects, negative interactions with anticancer drugs, and increased chemosensitivity of cancer cells, requiring a reduction in dose-density. Oncology HCPs working in countries in which herbal medicine use is prevalent need to better understand the implications of this practice. The presence of integrative physicians with training in complementary and traditional medicine can help patients and their HCPs reach an informed decision regarding the safety and effective use of these products.

Integration of complementary medicine in supportive cancer care: survey of health-care providers' perspectives from 16 countries in the Middle East.

INTRODUCTION: In this multinational Middle-Eastern study, we assessed health-care providers' (HCPs) perspectives on their patients' use of complementary and traditional medicine (CTM) and identified the leading barriers to CTM integration in supportive cancer care. METHODS: A 17-item questionnaire was developed and administered to HCPs attending palliative medicine workshops conducted across the Middle East by the Middle East Cancer Consortium. RESULTS: 339 HCPs from 16 countries across the Middle East completed the questionnaire (80.3 % response rate). Respondents perceived their patients' reasons for CTM use primarily in the context of cancer cure (63 %) and quality of life (QOL) improvement (57 %). Expectation regarding CTM's role in cancer cure/survival was more pronounced in Turkey, Jordan, the Palestinian Authority, and the Persian Gulf area. In contrast, the expectation that CTM would improve QOL was more emphasized in Israel. A mid-position between the cure/survival and QOL poles was observed in Cyprus, Lebanon, and the North African countries. Leading barriers to CTM integration in supportive cancer care included oncologists' skepticism and a gap between patients' expectations and HCP's objectives. Respondents' leading recommendation to HCPs was to communicate integrative care emphasizing well-being and improved functioning in accordance with their patients' health beliefs. CONCLUSION: CTM integration in supportive cancer care can be facilitated by implementing a platform for Middle Eastern clinical collaborations. HCPs' expectations and experiences with CTM have been positive in the oncology setting. These data need to be corroborated with information of patients' expectations on the provision of CTM over all phases of the oncology treatment.